ABSTRACT
Adequate assessment of anthropometry and feeding pattern is of critical importance in children so as to identify those with poor diet who are at increased risk of becoming stunted, underweight, wasted, overweight or obese. This study was conducted to determine the anthropometric status and feeding pattern of children aged 6-12years and compare between children attending public and private schools in Umuahia North Local Government Area, Abia State. A cross sectional comparative study was conducted among 356 children who were randomly selected from four public schools and four private schools in Umuahia North LGA, Abia State. A well structured and validated questionnaire was used to collect information on the socioeconomic data, anthropometric data and feeding pattern of the children. Descriptive statistics was used to sort the anthropometric characteristics and WHO anthropometry software was used to evaluate the height for age z-score (HAZ), weight for age z-score (WAZ), weight for height z-score (WHZ) and basal metabolic index for age z-score (BAZ). The study revealed that equal percentage (1.7%) of children had height for age (stunted) in both public and private schools. About 5.1% of the children in public schools had weight for height (wasted) while 9.6% of the children in private schools had weight for height (wasted). BMI for age (overweight/obese) was seen to be higher in private (7.9%) schools than in public schools (1.7%). BMI for age (overweight/obese) was also found to be higher among children aged 6-9years in both public and private schools. The p value for BMI for age showed a significant association (p=0.002) with the age of the children in public schools. In private schools, the mother’s educational level was significantly associated with stunting (p=0.000) and underweight (p=0.000). None of the high income earners had a stunted, wasted, underweight and overweight child but in private schools, high income earners had 25.0% wasted and 28.6% overweight children. The implication of this study is that children are the most vulnerable members of the society in Nigeria and the nutritional status of these children should be a primary indicator of socioeconomic development. The existence of malnutrition among school age children which is affected by poor feeding pattern will hinder the socioeconomic development of the society and also lead to waste in human potential.
TABLE OF CONTENTS
Title
Page i
Certification
page ii
Declaration iii
Dedication iv
Acknowledgement v
Table of
Content vi
List of
Tables x
Abstract xi
CHAPTER 1
INTRODUCTION
1
1.1 Background
of the Study 1
1.2 Statement
of the Problem 6
1.3 Objectives
of the Study 9
1.3.1 General
objective of the Study 9
1.3.2 Specific
objectives of the Study 9
1.4 Significance
of the Study 10
CHAPTER 2
REVIEW OF RELATED LITERATURE 11
2.1 Malnutrition
in Nigeria 11
2.1.1 Wasting
12
2.1.2 Causes
of wasting 13
2.1.3 Underweight 13
2.1.4 Treatment
of underweight 14
2.1.4.1 Diet 14
2.1.4.2 Exercise 15
2.1.4.3 Appetite
stimulants 15
2.1.5 Childhood
obesity 16
2.1.5.1 Attitudes
toward obesity in different periods of life 16
2.1.5.2 Obesity
and stunting 17
2.1.5.3.1The effect of obesity on motor
performance at different ages 19
2.1.5.2 Cause
of obesity 21
2.1.5.2.1 Behavioural
and social factors 22
2.1.5.2.1.1 Diet
22
2.1.5.2.1.2 Calorie
intake 23
2.1.5.2.1.3 Fat
intake
24
2.1.5.2.1.4 Other
dietary factors 24
2.1.5.2.2 Physical
activity 25
2.1.5.3 Prevention
of obesity 26
2.1.5.4.1 What
age group is the priority for starting prevention? 26
2.1.5.4.2 Build
a healthy environment 27
2.1.5.4.3 Increase
physical activity 27
2.1.5.4.4 Restriction
on TV watching 28
2.1.5.4.5 Improve the food sector 29
2.1.5.5 Effectiveness
of the prevention methods
29
2.1.5.6 Alterations
due to obesity
30
2.2 Feeding
Pattern 34
2.2.1 Problems
of feeding pattern 36
2.3 Assessment
of Nutritional Status 38
2.3.1 Anthropometric
assessment 39
2.3.1.1 Height 39
2.3.1.2 Weight 41
2.3.1.3 Weight
status 42
2.3.1.4 Importance
of nutrition and weight status 43
2.3.1.5 Body
mass index (BMI) 43
2.4 Biochemical
Assessment 44
2.5 Clinical
Assessment 45
2.6 Dietary
Assessment 45
2.6.1 Food
frequency 46
CHAPTER 3
MATERIALS AND METHODS 54
3.1 Area
of Study 54
3.2 Study
Design 54
3.3 Study
Population 54
3.4 Sample
Size and Sample Size Calculation 55
3.5 Sampling
Technique 56
3.6 Preliminary
Activities 56
3.6.1 Preliminary
visits 56
3.6.2 Training
of research assistants 56
3.6.3 Informed
consent 57
3.7 Data
Collection and Instrumentation 57
3.7.1 Questionnaire 57
3.7.2 Anthropometric
measurement 57
3.7.2.1 Height measurement 57
3.7.2.2 Weight measurement 58
3.7.3 Assessment
of feeding pattern 58
3.8 Statistical
Analysis 58
CHAPTER
4
RESULTS AND DISCUSSION 59
4.1 Characteristics
of the Children in Public and Private Schools 59
4.2 Economic
Characteristics of Parents of Children 61
4.3 Income
of Parents and Demographic Characteristics of the Children 64
4.4 Feeding
Pattern of the School Children
66
4.5 Snack
Consumption Pattern of the Children
69
4.6 Feeding Pattern of the School Children
using Food Frequency Questionnaire 71
4.7 Consumption
of Meat and Meat Products, Legumes of the Children 74
4.8 Consumption
Pattern of Cocoa, Milk and Milk Products
77
4.9 Consumption
Pattern of Fruits and Vegetables 79
4.10 Anthropometric
Characteristics of the Respondents
82
4.11 Prevalence of Stunting, Wasting,
Underweight and BMI-for-age in Children in
Public and Private Schools 84
4.12 Prevalence of Stunting, BMI-for-age,
Wasting and Underweight by Age
Categorized in Public and Private Schools 86
4.13 Prevalence
of Stunting, Wasting, Underweight and BMI-for-Age among
Males
and Females in Public and Private Schools
88
4.14 Effect
of Parents Level of Education on the Anthropometric Status of Children
in Public and Private Schools 91
4.15 Effect
of Mothers Level of Education on Anthropometric Status of Children 92
4.16 Effect of Parents Occupation on the
Anthropometric Status of Children
in Public and Private Schools 95
4.17 Effect
of Mothers Occupation on the Anthropometric Status of Children 97
4.18 Effect of Family Income on the
Anthropometric Status of the Children in
Public
and Private Schools 99
CHAPTER 5
CONCLUSION AND RECOMMENDATIONS 101
5.1 Conclusion 101
5.2 Recommendations 103
REFERENCES 104
LIST OF TABLES
Table 4.1
Characteristics of the Children in Public and Private Schools 60
Table
4.2 Level of Education and
Occupation of Parents of the Children in Public and
Private Schools
63
Table 4.3
Income and Household Characteristics of Parents
65
Table 4.4
Food Consumption Pattern of the Children Studied by School Type 68
Table 4.5
Snack Consumption Pattern of the Children Studied by School Type 70
Table
4.6 Consumption Pattern of Cereal,
Roots and Tubers, Fats and Oil of the
Children
73
Table
4.7 Consumption
Pattern of Meat and Meat Product, Legumes of the Children 76
Table
4.8 Consumption Cattern of Cocoa,
Milk and Milk Products of the Children
78
Table 4.9 Consumption
Pattern of Fruits and Vegetables of the Children 81
Table 4.10 Anthropometric
Status of the Children
83
Table
4.11 Prevalence of Stunting,
Wasting, Underweight and BMI-for-Age in Children
in
Public and Private Schools 85
Table 4.12 Prevalence
of Stunting, BMI-for-Age, Wasting and Underweight by Age 87
Table
4.13 Prevalence of Stunting,
Wasting, Underweight and BMI-for-Age among
Males
and Females in Public and Private Schools 89
Table
4.14 Effect of Father’s Level of
Education on the Anthropometric Status of Children in Public and Private
Schools
91
Table
4.15 Effect of mother’s level of
education on the anthropometric status of children
in
public and private schools
94
Table
4.16 Effect of father’s occupation
on the anthropometric status of children in
public
and private schools
96
Table
4.17 Effect of mother’s occupation
on the anthropometric status of children in
public
and private schools
98
Table
4.18 Effect of family income on the
anthropometric status of the children in
public
and private schools
100
CHAPTER
1
INTRODUCTION
1.1 BACKGROUND OF THE STUDY
Many
years ago, the focus of international nutritionists was on childhood
malnutrition and the related problem of how to feed the worlds’ expanding
population, especially the children (Prentice, 2006). Today, the
World Health Organization finds the need to deal with the new pandemic of
obesity and its accompanying non-communicable diseases, while the challenge of
childhood malnutrition is still far from being over (Prentice, 2006). Deficiency
in macro and micronutrients has been the major problem among children in
low-income countries for many years (Jafar et
al., 2008; Chatterjee, 2002; Bamidele et
al., 2011). Nevertheless, owing to progressive urbanization,
economic growth and the associated changes in lifestyle, the energy balance is
shifting (Goran and Sun, 1998).
Childhood overweight and obesity is becoming
equally challenging, yet under-recognized, problem in many emerging countries
(Jafar et al., 2008; Wang et al., 2002; de Onis and Blossner,
2000; Samuelson, 2000). Childhood overweight/obesity
was previously a health problem for developed countries because of their high
calorie foods, labor-saving devices and dwindling levels of physical activity,
but it is now spreading to developing countries. These countries are now
reporting unprecedented levels of childhood obesity with substantially rising
trends every year (Agarwal, 2008). The problem of obesity exists
alongside the problem of undernutrition in many developing countries which
creates a double burden of nutrition-related ill health among children (Senbanjo and Oshikoya, 2010; Popkin et al., 2001) and this has been referred to as the
"double burden of malnutrition (DBM) (FAO, 2006).
Childhood obesity has been increasing over the
past few decades and is now a public health concern in developed and developing
countries (Karnik, 2012). Global estimates indicate that 43 million children
were overweight and obese in the year 2010 (Blossner, 2000). Over one-fifth of
overweight and obese children were from developing countries.
Globally, the prevalence of overweight is expected
to rise from 6.7% in 2010 to more than 9% in 2020 compared to the increase from
8.5% to 12.7% in Africa within the same span of time (Blossner, 2000).
Additionally, The International Obesity Task Force (IOTF)
report showed that one in ten children worldwide is overweight; a total of 155
million children and adolescents are overweight and around 30–45 million are
classified as obese. In children, obesity has serious
implications for health such as cardiomyopathy, pancreatitis orthopaedic
disorders and respiratory disorders (NIH, 2007; WHO, 2003). After a while,
obesity has psycho-social effects on children such as social isolation
and low self-esteem of obese children which can lead to overwhelming feelings
of hopelessness,
which in turn lead to depression (Joseph et al., 1996; Bowman and
Russell, 2001). Obese children do less well in schools
because of stress and anxiety, which interfere with learning
and create a vicious cycle in which the over-growing worry increases the
declining academic performance (Joseph et al., 1996;
Bowman and Russell, 2001).
Excessive weight gain is a
precursor to different physiological aberrations that ultimately predispose the subject to
morbidity and mortality later in life. Studies have shown that, large number of
adult chronic non-communicable diseases have their
origin during childhood (Gill et al., 2000; Pierre et al., 2003). Obesity
has deleterious effects not only to adults but also to school age children. It
impairs concentration in school activities and affects hygiene in general.
Obese children are victims and perpetrators of bullying in school (Janssen et al., 2004). In addition they have
increased health risks like diabetes mellitus, bronchial asthma, increased risk
of cardiovascular problems and being more prone to developing fracture. They
are also prone to further weight gain after a life changing event like
pregnancy. There is a link between untreated pre-pubertal obesity and obesity
in adulthood (Dietz, 1998; Guillaume and Lissau, 2002). Some would argue that because there are a lot of
children in the world who are hungry and starving, why should we care too much
about obesity, the health problem of affluence and a poor lifestyle? One never
sees an obese child from a poor Asian or African village, however, when the
economic situation in such countries improves, the prevalence of obesity
increases, as is the case in India, Brazil, Paraguay, Venezuela, South Africa,
and so forth (Jimenez-Cruz, Bacardi-Gascon, and Spindler, 2003). In most of
these countries, including Mexico, obesity and malnutrition coexist
(Jimenez-Cruz, Bacardi-Gascon, and Spindler, 2003). Thus, when problems such as
malnutrition, decreased immuno-resistance, infectious diseases, and other
health outcomes are improved, new health problems appear.
Childhood obesity has also been identified in lower
socioeconomic groups in the industrially developed countries, which suggests
that obesity is due mainly to poor lifestyle behaviors, such as the consumption
of cheaper fats and sugar products, commonly combined with reduced physical
activity. Given the widespread nature of obesity, particularly under conditions
of an improving economic and social situation, the adequate management of the
condition during growth is an urgent challenge for most countries of the world
(Florencio et al., 2001). The best
approach is the prevention of obesity by closely monitoring energy intake,
output, and turnover, mainly by monitoring diet and physical activity levels
from as early as possible in childhood, especially in children at risk (Davison
and Birch, 2001). Such individuals may include, for example, children with
obese parents or with a strong family background of obesity (Dietz, 1986;
Epstein et al., 1998; Parˇízková,
1977; Parˇízková, 1996; Burniat, 2002; Zwiauer et al., 2002). Based on large epidemiological studies, the
child-to-adult adiposity relationship is now well documented, although
methodological differences can hinder meaningful comparisons (Dietz, 1998;
Guillaume and Lissau, 2002). Fatter children are more predisposed to becoming
overweight or obese adults in spite of the findings that the correlation
between, for example, BMI assessed at an age younger than 18 years and adult
values is often only mild or moderate.
There is a call for the surveillance of trends of the
major risk factors for the double burden of mal-nutrition such as stunting,
underweight, obesity, dietary patterns etc (Rolland-Cachera et al.,
1997; Shumei et al., 2002; Thiam et al., 2006). Although several
genetic factors have been associated with obesity and its comorbidities,
environmental factors, have also been proposed as important determinants of
obesity (Hill et al., 2003;
Meirhaeghe et al., 1999). Therefore,
adequate assessment of feeding pattern is of critical importance in order to
identify children with poor diet and at increased risk for becoming
underweight, wasted, overweight or obese. However, the assessment of feeding
pattern is complicated because people consume meals as opposed to single
nutrients or foods. Several national epidemiological studies have examined
dietary intakes of toddlers and preschoolers. These studies have revealed
increased total energy intake, inadequate intake of certain nutrients (i.e.
fibre), excessive intake of other nutrients (i.e. total fat, saturated fat and
sugars) (Kranz et al., 2005; Devaney et al., 2004; Manios et al., 2008; Kranz et al., 2005) and low intake of fruits and vegetables (Ballew et al., 2000; Hampl et al., 1999). These observations indicate inadequacies in some
nutrients and foods; however, they do not reflect the overall diet quality. There are many
factors that can affect children's eating practices. Dietary pattern analysis has recently best known as a
holistic dietary approach to evaluate diet quality and examine whether
adherence to a certain pattern may be of benefit to human health (Jacques and
Tucker, 2001; Hu, 2002). Among the approaches proposed to determine dietary
patterns, dietary quality indices have received increased attention because
they capture the multi-dimensional nature of people’s diets, and also because
they are based on general dietary guidelines as guiding principles, which make
them objective (Michels and Schulze, 2005).
According to UNICEF. (2015), Nigeria is facing a
problem of child malnutrition and ranks second behind India among all countries
with the highest number of malnutrition cases. Almost 30 percent of Nigerian
children are underweight and that is more than double the proportion of
Ghanaian children who are underweight.
Results from a survey conducted by UNICEF (2014), shows that Nigeria has a
stunting prevalence of 32 percent among children less than 5 years of age;
while about 21 percent and 9 percent are underweight and wasted respectively.
Overall, prevalence of malnutrition in the North West and East regions are
higher than in the South. Nigeria’s rates of
severe wasting are among the highest in the world at 1.9 million children each
year. The factors associated with these patterns of weight status among the
school-age children included sociodemographic and socioeconomic factors,
feeding patterns and activity patterns (Adeomi et al., 2015).
The
prevalence of childhood obesity is on the rise since 1971 in developed
countries. The most prevalence rates of childhood obesity have been observed in
developed countries, however, its prevalence is increasing in developing
countries as well. The prevalence of childhood obesity is more in the Middle
East, Central and Eastern Europe (James, 2004). The vast body of literature supporting that
childhood obesity persists through adult life (Rooney et al., 2011) makes it very imperative to study and understand
factors associated with childhood obesity including knowledge of children
themselves towards obesity. There is need for a
collective approach to the prevention, treatment, and management of underweight,
wasting, overweight and obesity in developing countries such as Nigeria, and to
implement these prevention strategies as early as childhood by involving
families, schools and the whole community, particularly with respect to the
problems of the condition during the growing years. Published data regarding
weight status and feeding pattern of school children aged 6–12 years in Umuahia
is scarce.This
study is aimed at assessing weight status and feeding
pattern among school children aged 6 to 12years in Umuahia-North Local
Government Area, Abia State.
1.2 STATEMENT OF THE
PROBLEM
Childhood malnutrition remains a public health problem
in Nigeria as the status did not improve substantially during the last two
decades. The implications of this unrelenting situation for the well being of
children and the development of the nation as a whole are unacceptable because
malnutrition contributes to the high rates of morbidity, disability and
mortality among children (WHO, 2000). In addition, malnutrition constrains people’s
ability to fulfil their potential as it is also associated with impaired
growth, mental development and school performance, reduced adult size and
reduced work capacity, which in turn impacts on economic productivity at the
national level (Hart and Atinmo, 2003). Low body weight had
been reported to be associated with greater mortality risk; it was suggested
that people who are underweight do not have a lot of nutritional reserves to
call upon when illness does occur (Flegal et
al., 2005). High prevalence of underweight therefore makes these
age bracket vulnerable to infectious diseases such as malaria, pneumonia,
diarrhoea, measles and HIV/AIDS which is said to account for more than 70% of
the deaths in Nigeria. As long as underweight remains high in early childhood,
the likelihood of cutting down under-five mortality rates is low. Efforts must
therefore be intensified to improve the nutritional status of this age group as
this will contribute to their mental and physical development, as well as
improved health and school performance through reduced vulnerability to
diseases.
Wasting or thinness
is often associated with acute starvation and/or severe disease. Wasting
is a strong predictor of mortality among children under five. It is usually the
result of acute significant food shortage and/or disease. There are 24
developing countries with wasting rates of 10 per cent or more, indicating a
serious problem urgently requiring a response However, wasting
may also be the result of a chronic unfavourable condition. Provided there is
no severe food shortage, the prevalence of
wasting is usually below 5%, even in poor countries but the prevalence of
wasting in Nigeria is observed to be 7.9% (UNICEF/WHO, 2014). A prevalence
exceeding 5% is alarming given a parallel increase in mortality that soon
becomes apparent. On the severity index, prevalence between 10-14% are regarded
as serious, and above or equal 15% as critical. Lack of evidence of wasting in
a population does not imply the absence of current nutritional problems:
stunting and other deficits may be present.
Childhood obesity is a multisystem disease with potentially
devastating consequences (Must and Strauss, 1998). Several complications
warrant special attention. The prevalence of obesity in Nigeria is observed to
be 1.8% (UNICEF/WHO, 2014). As
with adults, obesity in childhood causes hypertension, dyslipidaemia, chronic
inflammation, increased blood clotting tendency, endothelial dysfunction, and
hyperinsulinaemia (Freedman et al.,
1999; Srinivasan et al., 2002). This
clustering of cardiovascular disease risk factors, known as the insulin
resistance syndrome, has been identified in children as young as 5 years of age
(Young-Hyman et al., 2001). Among
adolescents and young adults who died of traumatic causes, the presence of
cardiovascular disease risk factors correlated with asymptomatic coronary
atherosclerosis, and lesions were more advanced in obese individuals (Strong et al., 1999; McGill et al., 2000). Type 2 diabetes, once
virtually unrecognised in adolescence, now accounts for as many as half of all
new diagnoses of diabetes in some populations (Fagot-Campagna et al., 2000). Frequent pulmonary
complications include sleep disordered breathing (sleep apnoea), (Redline et al., 1999) asthma, (Figueroa-Munoz et al., 2001) and exercise intolerance
(Reybrouck et al., 1997). Development
of asthma or exercise intolerance in an obese child can limit physical activity
and thus cause further weight gain. Furthermore, serious hepatic, renal,
musculoskeletal, and neurological complications have been increasingly
recognised (Balcer et al., 1999; Strauss et al., 2000; Adelman et al., 2001; Goulding et al.,
2001).
1.3 OBJECTIVES OF THE STUDY
1.3.1 General
objective of the study
The
general objective of this study is to determine the anthropometric status and
feeding pattern of children aged 6 to 12years attending public and private
schools in Umuahia-North Local Government Area of Abia State, Nigeria.
1.3.2 Specific
objective of the study
The
specific objectives of the study are to:
(i).
Determine the social
characteristics of the children
(ii).
Determine the economic
characteristics of the children.
(iii).
Determine the demographic
characteristics of the children
(iv).
Assess the feeding
pattern of school children using food frequency questionnaire.
(v).
Determine the
anthropometric status of children aged 6 to 12years in Umuahia-North LGA using
anthropometry.
(vi).
Determine the prevalence of malnutrition
(underweight, overweight, stunting, wasting and obesity) between males and
females in both public and private schools.
(vii).
Compare the
anthropometric status of children in public and private schools in Umuahia
North LGA.
(viii). Compare
the feeding pattern and anthropometric status in both locations.
1.4
SIGNIFICANCE
OF THE STUDY
Body weight is related to health status. Good
nutrition is important to the growth and development of children. Individuals
who are at a healthy weight are less likely to develop malnutrition
(underweight, wasting, overweight and obesity), iron-deficiency anemia, heart
disease, high blood pressure, dyslipidemia (poor lipid profiles), type 2
diabetes, osteoporosis, oral disease, constipation, diverticular disease and
some cancers (Black et al., 2013).
Weight status screenings could provide
valuable information for monitoring trends at the state and local levels where
data are limited. It can assist in identifying children who are at risk for
poor weight related diseases. Healthy children results in healthy communities,
where the available resources match the needs. The significance for recent
advanced studies on children is the search for understanding of poor weight
related problems and the effective management of children who are, or who may
be at risk of, becoming underweight, wasted, overweight and obese. Most
importantly, this study will provide more knowledge to health workers, parents
and educators on the subject of the study. It will help the general public,
since no documentation has been made on this study in umuahia north, to be
aware of poor weight status as a growing disease in the country and the world
at large. It will help to determine the prevalence of underweight, wasting,
overweight and obesity in umuahia north. Also, research on the feeding pattern of
children provides insight into the providers who care for children, the
children themselves, and the communities in which they live and this will help
to determine the relationship between weight status and feeding pattern in
children.
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